Deck 42: Burns

Question 1

After assessing the burns on a client, the nurse documents the finding as "first-degree burns" in the client's medical records. Which assessment finding supports the nurse's documentation?
1)Superficial burns
2)Full-thickness burns
3)Deep partial-thickness burns
4)Superficial partial-thickness burns

Answer 1

1

Question 2

A nurse is caring for a client with severe bleeding from the right hand due to an injury acquired while working in a uranium mine. Which is a priority nursing intervention for the client?
1)Scheduling the client for right hand surgery
2)Administering IV fluids to the client
3)Removing and bagging the client's clothes and shoes
4)Enquiring about the length of employment on the current job

Answer 2

3

Question 3

The nurse is providing care to a client admitted to the intensive care burn unit with serious thermal burns. Which finding is indicative of improvement of this client?
1)Minimal tissue edema is present at the injury sites.
2)Increased levels of histamines promote circulation.
3)Colloidal osmotic pressure continues to decrease.
4)Catecholamines are increasing body metabolism.

Answer 3

1

Question 4

The nurse is caring for a client 48 hours after acquiring thermal burns. The client has a respiratory rate of 14 breaths per minute, temperature of 99°F (37.2°C), and oxygen saturation of 97%. Which nursing intervention is appropriate for this client? Select all that apply.
1)Maintaining a strict input and output
2)Applying topical antimicrobial agents
3)Administering acetaminophen for fever
4)Administering 100% oxygen to the client
5)Monitoring the client's pain level

Question 5

The nurse is providing care for a toddler admitted to the burn unit for scalding burns to both legs. During assessment, the nurse notices diminished pedal pulses and cyanotic skin color to the left leg. The toddler cries without provocation. For which reason does the nurse contact the health-care provider immediately?
1)Current pain management regimen is not effective.
2)Dressings are restrictive and suppressing circulation.
3)Wound infection is present and threatening sepsis.
4)Evidence indicates development of compartment syndrome.

Question 6

While caring for a client with thermal injury of approximately 50% of the total body surface area (TBSA), the nurse assesses stridor in the client. Which is the priority nursing intervention for this client?
1)Intubating the client
2)Elevating the client's affected extremities
3)Administering IV fluids to the client
4)Beginning cardiopulmonary resuscitation (CPR) on the client

Question 7

While assessing a client, the nurse finds the client's cheek epidermal skin is dry, reddened, and warm. The client reports pain and tenderness at the area. Which cause does the nurse suspect for the condition?
1)Overexposure to the sun
2)Radioactive exposure
3)Brief contact with hot objects
4)Direct contact with steam

Question 8

While caring for a client with full-thickness burns, the nurse finds the client is exhibiting manifestations of Curling's ulcer. Which classification of medication does the nurse anticipate being prescribed for the client?
1)Proton pump inhibitors
2)Narcotic analgesics
3)Osmotic laxatives
4)Broad-spectrum antibiotics

Question 9

A client with partial-thickness burns is hemodynamically unstable. By which route does the nurse administer analgesics to the client?
1)Oral
2)IV
3)Subcutaneous
4)Intramuscular

Question 10

A client arrives in the emergency department with burns. After assessing a client, the nurse determines there is no need for a diagnostic evaluation of the burns. Which type of burns does the nurse identify on the client?
1)Superficial burns
2)Full-thickness burns
3)Deep partial-thickness burns
4)Superficial partial-thickness burns

Question 11

A patient with an electrical burn to one hand and arm is admitted to the intensive care unit (ICU). Entrance and exit wounds of electricity exhibit full-thickness burns, with partial-thickness and superficial burns to the remaining area. Which nursing intervention is appropriate before the first prescribed dressing change?
1)Soak the bandaged area in a hydrotherapy tub
2)Keep dressings dry in order to debride the wounds
3)Medicate with an IV opioid before changing the dressing
4)Explain a lack of pain because nerve ends are destroyed

Question 12

A new nurse on a burn unit is assisting the regular nurse in caring for a client in the emergent phase with deep partial-thickness burns on almost 60% of the body. Which action by the new nurse requires correction by the regular nurse?
1)Encouraging a low-liquid diet for the client
2)Scheduling the client for skin grafting
3)Inserting a nasogastric tube into the client
4)Preparing the client for tetanus booster administration

Question 13

Which zone exhibits the greatest degree of thermal injury within the skin?
1)Zone of stasis
2)Zone of hyperemia
3)Zone of coagulation
4)Zone of osmotic pressure

Question 14

While assessing a client, the nurse finds evidence of superficial burns. Which treatment does the nurse anticipate to be beneficial for this client?
1)Analgesics
2)Tetanus booster
3)Topical antibiotics
4)IV fluids

Question 15

Parents bring a child to the emergency department because of the ingestion of a corrosive cleaner. Which physical manifestation does the nurse specifically expect to find during assessment?
1)Blisters on the hands
2)Intense tissue damage
3)Gray coloring of the skin
4)Loss of consciousness

Question 16

While assessing a client, a nurse finds the skin on the wrist appears pearl-pink, wet, and blistered and the client's dermis is exposed. The client reports exposure to nearly boiling water. Which diagnosis does the nurse make?
1)The client has superficial burns.
2)The client has full-thickness burns.
3)The client has deep partial-thickness burns.
4)The client has superficial partial-thickness burns.

Question 17

While caring for a client after a thermal injury, the nurse finds that the client is showing signs and symptoms of hyperkalemia. Which is the most important nursing intervention for this client?
1)Administering oral fluids to the client frequently
2)Applying a topical antibiotic on the burns as prescribed
3)Elevating the head of the client's bed immediately
4)Monitoring cardiac function through electrocardiogram

Question 18

The nurse is teaching a client preventive measures for scalds. Which statement does the nurse include in the teaching plan to ensure safety?
1)"You should wear cotton gloves while handling hot liquids."
2)"You should apply a moisturizer before handling hot liquids."
3)"You should set the temperature of the water heater below 140°F."
4)"You should apply oil to the container containing hot liquids before handling."

Question 19

A nurse in an emergency department is caring for a client with thermal burns on 30% of the body. Which nursing intervention prevents the risk of burn shock in the client?
1)Ensuring adequate fluid resuscitation
2)Elevating the head of the client's bed
3)Applying silver nitrate ointment on thermal burns
4)Administering potassium supplements to the client

Question 20

Which physiological change can be observed in the prodromal stage of radiation burns in a client who has been exposed to 200 rads?
1)Pruritis
2)Skin ulcers
3)Necrosis of tissue
4)Permanent damage to hair follicles

Question 21

The nurse is evaluating a client with thermal burns after providing adequate fluid resuscitation for 24 hours. Which assessment findings does the nurse evaluate as being expected for this client in response to the treatment and timeline? Select all that apply.
1)Blood pressure of 90/70 mm Hg
2)Heart rate of 80 beats per minute
3)Urine output of 1,500 milliliters per day
4)Cardiac output of 4.7 liters of blood per minute
5)Potassium levels of 6 milliequivalents per liter

Question 22

The nurse is caring for a client with a body weight of 60 kg and thermal burns on 50% of the total body surface area (TBSA) at the time of hospital admission. Calculate the nutritional supplementation required to promote wound healing in the client. Record your answer as a whole number. ____________________.

Question 23

While caring for a client with thermal injury, the nurse avoids overhydration from excessive fluid resuscitation. Which risk is the nurse preventing in the client? Select all that apply.
1)Collapse of alveoli
2)Upper airway tract infection
3)Increased loss of bronchial cilia
4)Decreased total lung compliance
5)Decreased oxygen levels in blood

Question 24

Which symptoms are associated with exposure to the highest levels of radiation? Select all that apply.
1)Nausea
2)Vomiting
3)Diarrhea
4)Constipation
5)Hypervolemia

Question 25

Which physiological changes occur in the body after a thermal injury? Select all that apply.
1)Decreased intravascular fluid volume
2)Increased systemic vascular resistance
3)Decreased pulmonary vascular resistance
4)Decreased fluid loss into the interstitial space
5)Increased potassium ion flow into the extracellular fluid